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FAMILY HEALTH ASSESSMENT

Working with families has never been more complex or rewarding than now.

Nurses understand the actual and potential impact that families have in changing the health status of individual family members, communities, and society as a whole.

Families have challenging health care needs that are not usually addressed by the health care system.

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How Do You Define a Family?

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Definitions of a Family

Historical definitions:

The environment affecting individual clients

Small to large groups of interacting people

A single unit of care with definable boundaries

A unit of care within a specific environment of a community or society

Current theorists:

Two or more individuals who depend on one another for emotional, physical, and economic support. Members of family are self-defined.

– Hanson & Kaakimen (2005)

The family is who they say they are.

– Wright & Leahey (2000)

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Inclusive Definitions of Family

“Family” means any person(s) playing a significant role in an individual’s life. This may include person(s) not legally related to the individual. Members of “family” include spouses, domestic partners, and both different-sex and same-sex significant others. “Family” includes a minor patient’s parents, regardless of gender of either parent … without limitation as encompassing legal parents, foster parents, same-sex parent, step-parents, those serving in loco parentis, and others operating in caretaker roles.

– Human Rights Campaign ( 2009)

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The Changing Family

Purposes of the family

To meet the needs of society

To meet the needs of individual family members

Examples of different family types

Traditional, nuclear family

Multigenerational family household

Cohabitating families

Single-parent families

Grandparent-headed families

Gay or lesbian families

Unmarried teen mothers

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The “Sandwich” Generation

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Figure 20-1 From Pew Research Center: Social and Demographic Trends: The Sandwich Generation. http://www.pewsocialtrends.org/2013/01/30/the-sandwich-generation/. Accessed March 15, 2013.

Why Is It Important for the CHN to Work with Families?

The family is a critical resource.

Any dysfunction in a family unit will affect the members and the unit as a whole.

Case finding can identify a health problem that leads to risks for the entire family.

Nursing care can be improved by providing holistic care to the family and its members.

– Friedman, Bowden, & Jones (2003)

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Approaches to Meeting the Health Needs of Families

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Moving from the Family to the Community

Moving from the Individual to the Family

Moving from the Individual to the Family

Family interviewing

Manners

Therapeutic conversations

Genogram and Ecomap

Therapeutic questions

Commending family or individual strengths

Issues in family interviewing

Many locations, family informant, family health portrait, involvement of children

Intervention in cases of chronic illness

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Moving from the Family to the Community

The health of communities is measured by the well-being of its people and families.

Families are components of communities.

Cross-comparison of communities must include health needs as well as resources.

Cross-compare the needs of the families within the community and set priorities.

Delegation of scarce resources is essential.

A double standard in public health is tolerated.

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Family Theory Approach

Any “dysfunction” that affects one member will probably affect others and the family as a whole.

The family’s wellness is highly dependent on the role of the family in every aspect of health care.

The level of wellness of the whole family can be raised by reducing lifestyle and environmental risks by emphasizing health promotion, self-care, health education, and family counseling.

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Family Theory Approach (Cont.)

Commonalities in risk factors and diseases shared by family members can lead to case finding within family.

Individual is assessed within larger context of family.

Family is vital support system to individual member.

– Friedman (1994)

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Systems Theory Approach

The family as a unit interacts with larger units outside the family (suprasystem) and with smaller units inside the family (subsystem).

– Friedman (1998)

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Healthy Families

Members interact with each other; listen and communicate repeatedly in many contexts.

Healthy families establish priorities. Members understand that family needs are the priority.

Healthy families affirm, support, and respect each other.

Members engage in flexible role relationships, share power, respond to change, support the growth/autonomy of others, and engage in decision making that affects them.

– DeFrain (1999) and Montalvo (2004)

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Healthy Families (Cont.)

The family teaches family and societal values and beliefs and shares a religious core.

Healthy families foster responsibility and value service to others.

Healthy families have a sense of play and humor and share leisure time.

Healthy families have the ability to cope with stress and crisis and grow from problems. They know when to seek help from professionals.

– DeFrain (1999) and Montalvo (2004)

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Structural-Functional Conceptual Framework

Internal structure

Family composition, gender, rank order, functional subsystem, and boundaries

External structure

Extended family and larger systems (work, health, welfare)

Context: ethnicity, race, social class, religion, environment

Instrumental functioning (routine ADLs)

Expressive functioning

Emotional, verbal, nonverbal, circular communication; problem solving; roles; influence; beliefs; alliances and coalitions

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Developmental Theory

Family life cycle (Duvall & Miller, 1985)

Leaving home

Beginning family through marriage or commitment as a couple relationship

Parenting the first child

Living with adolescent

Launching family (youngest child leaves home)

Middle-age family (remaining marital dyad to retirement)

Aging family (from retirement to death of both spouses)

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Family Health Assessment Tools

Genogram

A tool that helps the nurse outline the family's structure

Family health tree

Family’s medical and health histories

Ecomap

Depicts a family’s linkages to their suprasystems

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Family Health Assessment Tools

Family Health Assessment

Addresses family characteristics, including structure and process and family environment

Information obtained through interviews with one or more family members, subsystems within the family, or group interviews of more than two members of the family

Additional information obtained through observation of family and their environment

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Genogram

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Figure 20-2 Redrawn from Genopro Software: Symbols used in genograms, 2009: www.genopro.com.

Ecomap

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Figure 20-4 Redrawn from Hartman A: Diagrammatic assessment of family relationships, Soc Casework 59:496, 1978.

Social and Structural Constraints

Identify what prevents families from receiving needed health care or achieving a state of health

Usually based on social and economic causes

Literacy, education, employment

If disadvantaged, often unable to buy health care from private sector

Hours of service, distance and transportation, availability of interpreters, and criteria for receiving services (age, sex, income barriers)

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Family Health Interventions

Institutional context of family therapists

Ecological framework: A blend of systems and developmental theory that focus on the interaction and interdependence of families within the context of their environment

Social Network Framework: Involves all connections and ties within a group; social support

Transactional model: A system that focuses on process as opposed to a linear approach

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Applying the Nursing Process

Knowledge of self, previous life experiences, and values is crucial in planning home visits

Gather referral information, review assessment forms, and gather intervention tools (e.g., screening materials, supplies) before going to the home

Flexibility is important in working with families

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